Oral Medicine V - Brennan's Bespoken Bane Flashcards by Tim Agee

Dyskinesias affect the jaw

Levodopa

True

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What is the ideal pre-Tx drug regimen for Parkinson’s pts?

Take meds 60-90 minutes prior to appt

*peak response period

**also, brief visits

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Palpitations:

A-fib

atrial fibrillation

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An estimated 2.6 million Americans have A-fib, number is increasing, and is responsible for ______% of all Strokes

15-20%

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4 comorbidities to A-fib

Coronary artery disease

CHF

Diabetes

Thyrotoxicosis

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3 Therapies for A-fib

Meds (Antithrombotics, combo, alternative)

Cardioversion

Ablation

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New Comparative Study, Tx of CVA can be safely administered w/in what time period?

As long as what?

A few weeks of CVA

Kept under optimal medical surveillance

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Most common Inherited Clotting Disorder:

Hemophilia A

(1 in 5,000 male births)

Hemophilia B

(1 in 30,000 male births)

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Hemophilia A is a Factor ___ deficiency (80%)

Hemophilia B is a Factor _____ deficiency (13%)

6% is a factor ____ deficiency

Factor VIII

Factor IX

Factor XI

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Vitamin K rich foods are

Green

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If you lack one coagulating factor it is…

If you lack multiple coagulating factors it is….

Inherited disorder

Acquired disorder

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4 Vitamin K factors made in the LIVER:

VII

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Factor XII, XI, IX

Factor VII

Intrinsic system/Tissue Factor pathway

Extrinsic system/Contact pathway

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3 lab tests for Coagulation Disorders

aPTT - Activated Partial Thromboplastin Time

PT - Prothrombin Time

Platelet Count

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aPTT tests the ______ system. What 4 factors?

PT tests the _______ system. What 5 factors?

Platelet Count deals w/ primary _____

Intrinsic VIII, IX, XI, XII

Extrinsic VII, V, X, prothrombin II, fibrinogen I

Hemostasis

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Some pts might not be forthcoming about bleeding disorders - what is an important question to ask?

Do you bleed or bruise easily?

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5 Uses for Warfarin

*what 2 have higher anticoagulation and higher risk of morbidity

Prosthetic Heart valves

Hx deep venous thrombosis

Stroke

Atrial Fibrillation

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What INR and PT levels would you not worry about (discontinuation not necessary for minor OS)

INR < 3.5

PT < 20 seconds

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Primary concern for pts on Warfarin:

Physician Consult?

Recourse for excessive bleeding:

Post Op:

Hemostasis

Order/review lab values - perioperative change likely

GelFoam/thrombin, bone wax, Amicar/Tranexamic acid rinses

Acetominophen/codeine

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PT < 20 seconds, INR < 3.5
These measurements should be takend w/in _____

You can make changes to anticoagulation therapy

24 hrs

False

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3 Issues w/ Warfarin:

Narrow therapeutic window

Frequent monitoring

Food/Drug interactions

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What consumables increase the effects of Warfarin?

What decreases?

Wine, cranberries

Green, Vitamin K rich foods

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Pain med interactions w/ Warfarin:

Abx interactions:

ASA, NSAIDS, Acetaminophen

Tetracycline, ampicillin, amoxicillin/clavulanic acid (augmentin)

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What Abx should you take w/ pt on Warfarin? (2)

Pen V or Clindamycin

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T/F | Lit supports altering anticoagulant regimen prior to dental procedures and surgery

False *go by 3.5 rule

Clinical judgement, experience, training, and accessibility to appropriate bleeding management strategies are all important components in any treatment decision

Frame and put on wall

3 Antiplatelet agents:

ASA (and NSAIDS) Ticlid Plavix

Antiplatelets are used primarily for prophylaxis of: Secondary prevention of adverse ________ in pts with Hx of _______, _______, and ______

Coronary Thrombosis Thromboembolic events Coronary thrombosis, Stroke, Unstable Angina

Do NOT mix up coagulation factors w/ Anti-Platelets - What does INR measure?

Coagulation (warfarin) NOT platelets (ASA, etc)

Best test for ASA platelet effect is PFA 100 or Ivy bleeding time Not a problem unless Bleeding time is greater than ______

True 20 minutes

NSAIDS will increase bleeding time how? Generally you must wait 3 half lives (w/ wide variance between drugs)

Antiplatelet True

6 ways to increase clinical risk of bleeding through antiplatelet activity:

ASA NSAIDS EtOH Age Liver disease existing coagulopathies

Clinical recommendation for pts on Antiplatelet therapies:

Little/No indication to interrupt antiplatelet drugs for dental procedures

It is not necessary to interrupt low dose aspirin therapy for simple dental extractions

True *really any ASA dose

Drug Eluting Stents (DES) is often clopidogrel, plavix, etc and when combined with ASA...

Decreases cardiac events after stenting

DES, premature discontinuation of antiplatelet therapy greatly increases the risk of what 3 things?

Stent Thrombosis MI Death

DES usually has ASA/Plavix dual Tx for how long after Stent placed? Postpone Elective surgery for how long? If surgery cannot be deferred, what do?

12 months 12 months continue ASA perioperatively

3 reasons for Warfarin replacement drugs:

Wide therapeutic index Few Drug/Food interactions Predictable anticoagulant response at fixed doses

3 new oral Anticoagulants (Warfarin replacements)

Dabigatran Rivaroxaban Apixaban

New oral Anticoagulants (Xarelto, etc) have what major flaw

No reversal agent

What is the reversal agent for Warfarin? New drugs?

Vitamin K nothing

If pt taking new Anticoagulants, what 3 lab tests do you need prior to surgery?

aPTT TT anti-factor Xa

Warfarin acts on what 4 clotting factors: Unfractioned Heparin on what 2: Rivaroxaban (and Apixaban): Dabigatran:

VIIa, IXa, Xa, Thrombin Xa, Thrombin Xa Thrombin

2 new drugs act on Factor X: 1 new acts on Factor II (Thrombin):

Rivaroxaban, Apixaban Dabigatran

T/F | It does not appear Dabigatran discontinuation is necessary (if renal function, etc ok)

True

Type 1 diabetics have a deficiency of insulin secondary to destruction of what cells? Type II is either faulty receptors to insulin or antibodies to those insulin receptors or insulin itself In either case, what is the result?

Beta cells True Hyperglycemic State

Hyperglycemia, short term polyphagia, polyuria, polydipsia, ketoacitosis/hyperosmotic coma What is the long-term consequence?

Microangiopathy *and deposition, delayed healing, infection

Diabetes Diagnosis, blood Glucose: HbA1c must be what in well-controlled diabetics:

>126 mg/100mL <7%

Xerostomia, Infection, poor wound healing, increased perio/caries, etc

Diabetes

There is a significant bleeding risk in Diabetes

False

Epinepherine concern in Diabetes:

epi in LA increases blood Glucose

Well-controlled diabetics can tolerate dental care _____ If cardiac complications...

normally precautions

Diabetes: Morning appts, pts eat normally. Have what to monitor? What in case of hypoglycemia?

Glucometer fast-acting carbs

In uncontrolled diabetes, provide what care only?

Emergency

Controlled diabetics Abx Uncontrolled:

like everybody else heightened risk for Infection (Use post-op Abx)

Normal thyroid feels... Enlarged feels...

rubbery soft

If untreated Hyperthyroidism, avoid... If untreated Hypothyroidism, avoid...

Epi CNS depressants

Hydrocortisone (100-300 mg), CPR, IV glucose Tx for crisis in both Hyper and HypoThyroid

True

In well-controlled thyroid disease, Tx infections normally

True

Osteoporosis of alveolar bone, caries, etc Cretinism, enlarged tongue, etc Pain to ear, jaw, occiput, dysphagia, enlarged, firm nodular, and tender thyroid

Thyrotoxosis Hypothyroidism Thyroiditis

Possible labe tests for organ transplantation Bleeding time: liver disease: renal disease:

platelet count, WBC count, hematocrit AST, ALT, alkaline phosphatase, PT, bilirubin creatinine, BUN, specific gravity urine, proteins in urine, hematocrit, WBC, pTT

3 important factors in Dentistry to consider in pts w/ transplants:

bleeding infection build-up drugs/toxic metabolites (liver/kidney)

Oral signs of Immunosuppression include HSV, apthous, CMV, candidiasis...

Mucositis

Bone Marrow suppression drug that Increases chance for infection: affects liver/kidney, causes gingival hyperplasia

Azathiprine Cyclosporine

Avoid dental care Tx for how long after a Transplant?

6 months

Pre-transplant Tx

Med consult prophy Abx, other mods, labs

4 Drugs to Increase Interval/Change after Organ Transplant

Acetaminophen Penicillin V Cephalexin Tetracycline (or Doxy)

If Abx prophylaxis, give what ideally? plus... If allergic? or Impenem, dosage: Can't take orally: plus... What shouldn't be used in Organ Transplant pts b/c of acute Liver Toxicity?

Amoxicillin, 2g orally 1 hr prior 500 mg oral 1 hr prior Vancomycin, 1g IV infused slowly over 1 hr prior 1g IV infused 1hr infused slowly prior Apicillin, 2g IV 1 hr prior metronidazole 500 mg IV 1 hr prior Clindamycin

Transplant issues, anticoagulation via meds, rejection Stress - may need steroid supplementation if adrenal suppression Mucositis, viral infection, aphthous, etc

True

Blood Glc reading = 65

Tx w/ fast acting carbs

Post-op Abx in Diabetes:

only for Uncontrolled

Uncontrolled Diabetic Cardiac Guidelines:

None *no subset here, follow Cardiac Guidelines

Fasting Glucose threshold for Diabetes:

126 mg/100 mL

If pt on ASA, what lab test prior to Extraction?

None *nothing for Anti-platelets!!!

Warfarin affects what clotting factors (number and name):

VIIa (tissue factor) IXa Xa IIa (Thrombin)

Extrinsic, Tissue Factor pathway, what Factor?

VII

Med Consult during Chemo? Postpone when Platelets below... or Neutrophils below...

Always 50,000 1,000 mm3

Tx of Uncontrolled Diabetics when?

only during Emergency

Parkinson's, take meds _-_ minuted prior and keep brief

60-90 minutes prior

Old research on stroke, wait.... New research, Tx w/in ____ as long as surveilled

6 months a few weeks

4 Vitamin K dependent factors:

II, VII, IX, X *warfarin

Clotting factor II: IIa: I: Ia:

Prothrombin Thrombin Fibrinogen Fibrin

If on Warfarin, INR < PT < Should be measured w/in

3.5 20 sec 24 hrs

New drug, Thrombin inhibitor: 3 Factor Xa inhibitors:

Dabigatran (Pradaxa) Rivaroxaban, Apixaban, Edoxaban

2 Abx ok to use w/ Warfarin:

PenV Clindamycin

Asthma, instruct pt to bring Inhaler, consider _____ if severe. Emergency, use...

pulse ox during Tx Ventolin/Proventil (short acting beta 2 adrenergic)

COPD 4 clinical considerations:

Stability of pt chair position avoid Rubber Dam Low-flow supplemental Oxygen

Almost everyone w/ Asthma has what Drug Allergy?

ASA

Chronic Bronchitis, chronic cough w/ sputum production for what time period?

3 consecutive months 2 successive years

Hypercapnea

too much CO2 (COPD)

Theophylline:

COPD (Stevens-Johnson syndrome)

Unstable COPD pt (below 91% Oxygen) must have what 2 mods?

Upright Pulse ox

Stable COPD, ok to use diazepam must be upright

True True

Early stage tumors: Advanced stage:

surgery chemoradiotherapy

Pre-cancer oral health exam should be done when?

1 month prior cancer Tx

Common radiation side-effect

Trismus *difficulty opening

Radiation Therapy, dental procedures should be done how long prior? If ortho bands fabricate... Endo in field: Endo out of field: avoid removables, fabricate dentures _____ post surgery/radiation

10-14 (idally 21) to heal remove custom gel-applicator Extract, no re-treats RCT can be done 3-4 months

If chemo, ask Oncologist cancer, stage, palliative/curative, prognosis blood: clotting factors: Tx schedule (so safe dental Tx can be delivered)

True CBC, neutrophil, platelet if invasive true

If possible, all dental Tx should be done ___ prior to Chemo Extractions should be done how long prior ideally? minimum?

1 week 3 weeks 10-14 days

When do you need a Med Consult if pt on Chemo?

Always *even prophys

If pt on Chemo, when would you postpone Tx? (2 cases)

platelet count < 50,000 neutrophil count < 1,000

When would you schedule a Chemo pt?

17-20 days post Tx (when they feel best)

Hematopoietic stem cell transplantation:

Intentional destruction of Marrow stem cell transplant

3 types of Hematopeitic Stem cell transplants

Autologous (own cells) Allogenic (own species) Syngeneic (identical twin)

HSCT similar guidelines to Chemo

True

HSCT, delay elective procedures for how long? Greatest risk of complications:

1 year 100 days

*180 days autologous, 365 allogeneic for standard care

True

Painful, ulcerative oral complication of Radiation

Oral Mucositis

Mucositis, xerostomia, candidiasis, osteoradionecrosis, | Trismus

Radiation

Mucositis, ural ulceration, anemia, thrombocytopenia, infection, neurotoxicity, osteonecrosis of the jaw, xerostomia

Chemotherapy

Anticonvulsants can modify the pathologic process and decrease orofacial pain

True

HSCT prevalence of Oral Complications:

80% *severe immunosuppression

GVHD manifests orally as atrophy, erythema, white striations, plaques (similar to lichen planus), xerostomia, taste changes, formation of mucoceles, and mucosal sclerosis

True

If neutrophil count is below 50,000, what is needed

Abx prophylaxis

All procedures 1 week prior to chemo 17-20 days post

True

If Controlled Diabetes what might you need to do prior to Tx

current HbA1c

Oral Medicine V - Brennan's Bespoken Bane Flashcards

(116 cards)